Locally Advanced Cervical and Upper Thoracic Esophageal Squamous Cell Carcinoma: Multimodality Treatment

22 Jan 2025 13:00 15:00
Beijing
You-Sheng Mao Host

Patient Profile & Initial Presentation

  • Patient: 25-year-old male

  • Clinical Presentation: Admitted for a 3-month history of dysphagia.

  • Pathology: Pathologically confirmed squamous cell carcinoma of the esophagus at 18 and 20-27 cm from incisors.

  • CT Findings: Two separate lesions located in the cervical and upper thoracic esophagus, with esophageal wall thickness of approximately 1.8 cm.

  • Lymph Nodes: Metastatic lymph nodes suspected in bilateral tracheoesophageal grooves and left supraclavicular area.

  • Clinical Diagnosis: Locally advanced cervical and upper thoracic esophageal squamous cell carcinomas, staged cT4aN2M0 (Fig. 1).

Time Schedule

  • Europe: CET: Paris: 1 – 3 pm

  • UK: 12 noon – 2 pm

  • North America: West Coast: 4 – 6 am; East Coast: 7 – 9 am

  • South America: São Paulo: 9 – 11 am; Buenos Aires: 9 – 11 am; Santiago Chile: 9 – 11 am

  • Africa: Bomet, Kenya: 3 – 5 pm

  • Asia: Beijing: 8 – 10 pm; Kuala Lumpur: 8 – 10 pm

  • Australia: Melbourne: 11 pm – 1 am (Jan. 23)

Free registration

Decision of Multimodality Treatment

Neoadjuvant Treatment

  • Period: November 2019 to March 2020.

  • Regimen: 5 cycles of chemoimmunotherapy, one cycle every 3 weeks.

  • Albumin Paclitaxel: 200 mg / days 1 and 8.

  • Cisplatin: 60 mg / days 2 and 3.

  • Pembrolizumab: 200 mg / day 1.

  • Toxicity: Tolerable grade II myelosuppression experienced during this period, with appropriate management.

Preoperative Radiotherapy

In April 2020, preoperative radiotherapy was performed for supraclavicular lymph node metastasis with larynx preservation.

  • Radiation Dose: 95% PTV 1.8 Gy, a total of 39.6 Gy in 22 fractions over 32 days (Fig. 2).

Surgery

  • Timing: Surgery was performed 8 weeks after completion of neoadjuvant treatments.

  • Procedure: MIE (McKeown procedure) with three-field lymph node dissection and laryngeal preservation.

  • Postoperative Pathological Stage: ypT0N0M0.

  • Surgical Margins: Negative.

  • Postoperative Course: Smooth recovery without complications. Discharge 8 days after surgery.

  • Postoperative Treatment: No postoperative treatment.

Postoperative Follow-up

  • 11 Months Later: Recurrence detected in left supraclavicular lymph nodes (metastatic LNs, 2/3).

  • Salvage Treatment: Salvage resection of left cervical metastatic lymph nodes.

  • 5 Years Following Initial Surgery: Extensive distal metastases were detected.

  • Final Outcome: Despite systemic chemotherapy, the metastases could not be controlled and the patient died.

Figures

Fig. 1. Preoperative esophagoscopy and CT scan

Inlet of the esophagus
Lesion at 20 cm from incisors
Lesion at 20-27 cm from incisors

Fig. 2. Esophagoscopy before treatment and after neoadjuvant therapy

Lesion at 20-27 cm from incisors after neoadjuvant therapy

Fig. 3. Reassessment of supraclavicular metastatic LN by CT

Pre-treatment
2 cycles of chemo-immunotherapy
5 cycles of chemo-immunotherapy
Pre-operative

Fig. 4. Reassessment of cervical esophageal lesions by CT

Fig. 5. Reassessment of thoracic esophageal lesions by CT

Fig. 6. Postoperative supraclavicular LN recurrence by CT during follow-up

Fig. 7. Postoperative supraclavicular LN recurrence by PET-CT during follow-up

Multi-disciplinary Panel

Beijing: You-sheng Mao | Yong Li | Zhen Wang | Ling Qi

Shanghai: Xufeng Guo

Guangzhou: Hong Yang

Sichuan: Yong Yuan

Topics for Discussion

  1. What is the current most effective multimodality treatment regimen for locally advanced esophageal cancer: chemo-radiation or chemo-immunotherapy or immuno-chemo-radiation?

  2. Neoadjuvant chemo-immunotherapy and radiotherapy: In recent years, many studies reported that neoadjuvant chemo-immunotherapy could achieve similar PCR rate as chemo-radiation, which was currently still recommended as a standard neoadjuvant treatment for esophageal cancer. Could chemo-immunotherapy replace radiotherapy in the future, or could chemo-immunotherapy followed by sequential radiotherapy improve PCR rate?

  3. Postoperative immunotherapy and surveillance: This is a successful case treated by neoadjuvant therapy followed by radical surgery in conventional multimodality treatment for locally advanced esophageal cancer. However, the patient died of recurrence although yPCR and complete resection were achieved. Will yPCR patients still need postoperative immunotherapy? Is there any effective follow-up examination to find micro-residual lesions?

  4. Esophagus preservation: Esophagus preservation is becoming more and more potential if CCR is achieved after neoadjuvant therapy such as chemoradiation or chemo-immunotherapy or even immuno-chemo-radiation for esophageal cancer patients. What is the most effective neoadjuvant regimen that should be selected for esophageal cancer patients? If CCR is achieved after neoadjuvant therapy, should standard surgical resection be decided for the patient, or just close follow-up and subsequent salvage surgery after detection of local recurrence?